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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336423661
Report Date: 08/05/2022
Date Signed: 08/05/2022 03:19:25 PM


Document Has Been Signed on 08/05/2022 03:19 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:AGAPE CARE HAVENFACILITY NUMBER:
336423661
ADMINISTRATOR:MARIE HUNGFACILITY TYPE:
740
ADDRESS:3750 BRISCOE STREETTELEPHONE:
(951) 682-7608
CITY:RIVERSIDESTATE: CAZIP CODE:
92506
CAPACITY:6CENSUS: 5DATE:
08/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:ADMINISTRATOR DARLY LEETIME COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced for the purpose of completing the facility's Annual Inspection. LPA Mixson met with Administrator, Daryl Lee and advised of the purpose of the visit, and that the visit will focus on Infection Control only.

Present in the facility were 5 residents and 2 caregivers. Currently there are no cases of COVID-19 within the facility.

LPA Mixson observed residents have hand sanitizer available to them, and all resident bathrooms were stocked with liquid soap and paper towels. LPA Mixson observed sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions and the proper use of face coverings.

The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, and cleaning and disinfection provisions are in adequate quantities. LPA Mixson later discussed infection control practices and procedures with Administrator.

An exit interview was conducted, and a copy of this report, along with the LIC 811 was provided to Administrator.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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